Triple assessment of breast lump

To determine the sensitivity, specificity, positive and negative predictive values of triple test (TT) consisting of physical examination (PE), mammography, fine needle aspiration cytology (FNAC) in the evaluation and characterization of palpable breast lump. Secondly, whether this can be employed as an alternative for tru cut/ excisional biopsy.

Cross-sectional study.

This study was conducted in the department of diagnostic imaging, Shifa International Hospital (SIH), Islamabad in collaboration with departments of surgery and pathology from January 2004 to June 2005.

It comprised of 35 consecutive females presenting in the breast clinic with palpable lump. Females below 35 years of age were excluded due to low sensitivity of the mammography in depiction of focal breast lesions resulting from glandular parenchyma. Patients with acute inflammatory signs, fungating masses, pregnant ladies as well as those with cystic lesions, as confirmed by ultrasound, were also excluded from the study. Number, size and recurrent masses did not influence the inclusion criterion. Detailed history and physical examination was carried out as per established protocol. It was followed by mammography and FNAC. All cases underwent excisional biopsy irrespective of the results of the triple test.

The patients' age ranged from 35 to 75 years with mean age of 45.97. Amongst these, 19 cases were benign (54.28 %) and 16 cases (45.71 %) were malignant. The triple test (TT) was scored as concordant if the elements had either all malignant or all benign results. The triple test was non-concordant if the elements had neither all malignant nor all benign results. The TT was concordant in 19 cases (54.28 %) i.e all the benign cases detected by the triple test were benign on final biopsy (100 % specificity and NPV), all the malignant lesions detected by TT turned out to be malignant on final biopsy (100 % sensitivity and PPV). Triple test was non-concordant in 16 cases (45.71 %). Triple Test was scored as benign or malignant based upon the combined results of two elements amongst three components. Out of these, 11 cases were malignant and 5 were benign. In 4 cases, the components of the triple test were suspicious i.e. BIRAD IV on mammography and slight atypical cells without frank malignancy on FNAC. In current study, suspicious cases were taken as malignant. These turned out to be malignant at the end signifying 100% PPV. However, among the 12 cases where, at least one of the 3 components of TT was benign, FNAC was most accurate (2 False Negative (FN) and 0 False Positive (FP), followed by mammography (2 FN and 3 FP) and physical examination was least accurate with 3 FN and 4 FP. It is of note that in 2 cases where FNAC gave FN results, the other two components were either suspicious or malignant. In those cases where two variables were malignant, FNAC and mammography were most accurate with no false positive or false negative. It was followed by physical examination and FNAC with 1 false negative and no false positive.

The study shows that when TT is concordant, final treatment may be ensued without open biopsy. In non-concordant cases, FNAC stands as single most important investigation. However due to its false negative results, other components of triple test need to be employed to enhance its efficacy and diagnostic yield. TT is cost effective, easy to perform and time saving approach, however, it can be applied only in those institutions where excellent imaging facilities as well as services of a cytopathologist are available. Due to small sample size, the results of this study needs further verification by relatively larger scale studies.